Just Like Someone Without Mental Illness Only More So

by Mark Vonnegut, M. D.

  The process whereby one gets to be a doctor is one where you pretty much have to be a grade-and-approval junky. This eventually has unfortunate consequences—all a hospital or insurer or pharmaceutical company has to do to get doctors to jump through hoops is set up a grading system and put some doctors in tier one and others in tier two or three or four. The courage to do the right thing in the face of disapproval is often lacking.

  There is a dangerous point in the deliberation process of the admissions committee where the application has been formally presented and one of the people who interviewed the candidate briefly defends why he gave the candidate a 9.5 or 10.0. There’s a pause where anyone on the committee can say anything. If the next thing that’s said is strongly positive, the application will sail on to the next level, but if someone says, “A bit thin on the extras,” or “Were they involved in the community?” or, worst of all, “It’s a strong application, but is this applicant really right for here?” the fate of the otherwise strong applicant twists in the wind. Trying to defend someone at this point almost seems to make it worse. If the application needs your help, how good could it be?

  People don’t apply to Harvard Medical School lightly. They are all standing on a lot of shoulders. We were passing judgment on some of the most absurdly intelligent, accomplished, highly motivated men and women the world had ever produced.

  The curse of having to be important dooms a lot of us. Living up to all that white marble and the tree Hippocrates taught under and the admissions process is not easy. If you become a doctor to make a difference, it turns out that no difference you can make is enough. Unambitious people aren’t going to be applying to or getting into medical school, but once an ambitious person gets in, she has to either win a Nobel Prize or learn how to be of service to ordinary people with unglamorous problems.

  If it wasn’t for questions like “How high’s the fever?” “How many days has he been sick?” or “Diarrhea?” I wouldn’t know what to say to people. Whether or not children eat vegetables has consumed a significant part of my professional life. Nobody I’ve interviewed for medical school has said they want to get really good at treating diaper rashes and quieting crying babies and frightened children. Life-or-death comes up less often than you might imagine and when it does the doctor’s power to change the outcome is limited. If you’re saving your energy for the big important moments, you’re going to be saving a lot of energy. People who are trying to die are trying to tell us something.

  ——

  “What problems are young people having today?” I was asked at a harmless social get-together at the home of the dean of admissions.

  The problem for young people today is the Harvard Medical School admissions committee. People this bright and accomplished shouldn’t have to be begging for a job in medicine. It shouldn’t be so hard. There should be more clearly defined, simple paths for people to be of use. That so many young people want to be doctors speaks well for the families producing intact applicants and for medicine for attracting them, but I can’t help feeling that there should be a broader array of choices. People that intelligent who have worked that hard should be able to be doctors if they want to. What exactly is the point of producing an abundance of amazingly capable people if we don’t have more things for them to do? Two hundred years ago being able to read and write a little, being healthy and having a work ethic, meant you could do well at just about anything.

  It shouldn’t be so hard for people to figure out what to do with their lives.

  “What the hell are we going to do with Timmy?”

  “I don’t know. Do you think we could get him into med school?”

  Every Nobel laureate was once a goofy sixteen- or twenty-two-year-old whose family worried about what the hell he or she was going to end up doing.

  I have had heartbreakingly accomplished patients kill themselves or become heroin addicts. It’s not enough to play an instrument perfectly or to get a full scholarship.

  As soon as a new hurdle is set on the path to getting into medical school (organic chemistry, higher and higher GPAs, higher and higher board scores, extracurriculars, community service, moving personal stories, et cetera), the ability to clear that hurdle spreads through the applicant pool like the ability to resist penicillin spreads through a petri dish. Everybody is throwing a lot of pasta up against the wall hoping that it will stick. Any essay that works will be reworked and reworked and reworked some more.

  Some applicants were accused of trophy collecting. It wasn’t enough to be a concert pianist, work in a first-rate research lab, or save a small South American village. It had to come from the heart.

  After watching so many candidates I liked go up in flames I suggested to the dean that each committee member be allowed to advance one applicant a year to the final pool without the usual debate. He thought it was a good idea and would bring it up to the committee.

  Is a doctor really that special a thing to be, or are we making too big a deal of this? It’s like we’re all scrambling to get to a place a little higher up on some slippery pyramid because we don’t know how high the water will be when the tide comes back in.

  Sometimes my father would call me out of the blue. “Is this the doctor on call?”

  “Yes, it is, Dad.”

  “Sorry about your profession. I wouldn’t be a doctor for anything. That’s got to be the worst job in the world.”

  When I became a pediatrician, a short visit cost ten dollars, a checkup was twenty. People paid cash. Our overhead was 27 percent. Our books were kept on a yellow pad. We were free to determine the content of the visit, which mostly consisted of asking patients or parents what we could do for them and taking it from there. When medical insurance came into pediatrics, it seemed like a good deal because we would suddenly be paid twice as much for visits and procedures and our patients wouldn’t be paying anything out of pocket, since it would all come out of the insurance that was taken out of their paychecks. We also realized we had no choice, since no matter how much they loved us, most families would take their kids where the care was covered by their insurance. We also had to get computers and hire people to track whether or not we got paid and do a bunch of other stuff. There goes the overhead.

  In the fine print it became illegal for us to charge the uninsured or anyone else less than we charged our insured patients and it also stipulated that the insurer would pay us at a discounted rate for our charges. The net effect was that my professional services went from something my patients could easily afford to something that, without insurance, they couldn’t.

  When I ask pharmaceutical salespeople what a new drug costs, they hasten to reassure me that it’s covered by insurance and will only cost the patient a ten- or twenty-dollar co-pay. Co-pays are the tip of the iceberg. Without insurance all these new, absurdly expensive medications could not exist. With insurance it becomes suddenly worthwhile for pharmaceutical companies to spend millions and billions pushing less-than-necessary medications to providers and patients. These costs push up the cost of other medications and insurance and care in general. If you believe that the dollars made by the pharmaceutical industry are plowed back into research that leads to better and better medications, you probably believe in the tooth fairy as well.

  A dispassionate look at all the many innovations of the insurance industry, from HMOs and managed care to co-pays and prior authorizations, would show that each innovation was a way for insurers to make money at the expense of the public good. If these innovations were studied like a new drug or medical device, they would be taken off the market.

  What doctors should be doing as advocates for their patients—as advocates for change—is grading and reviewing the hospitals and insurers, but instead they cower in fear. Doctors get to be doctors by knuckling under, but at some point, for the good of their patients, they should wake up and insist on being in charge.

  Both the medical insurers and drug companies make and hold on to as much of the money as they
can. They have, to a large extent, subverted the efforts of hospitals and other providers to care for the sick. The sick have been converted into financial instruments whereby large amounts of money are transferred from one corporation to another. The business opportunities presented by sickness and the threat of sickness have cast into outer darkness the opportunity for medical practioners to be of help and service.

  A hundred years ago the Flexner Report revolutionized medical education and medical care by emphasizing science and paying attention to what happened to patients. It’s always possible that history will repeat itself. Maybe today’s medical students or the next generation or the next will say, “No. This is how it should be done. First, do no harm, care about what happens to patients, and settle arguments with good science.”

  You Can’t Ignore Gravity, 2008

  (Painting by Mark Vonnegut)

  chapter 13

  Short Chapter …

  Relationships are absurd spindly contrivances

  Of Love Lust + Luck

  How sad when we see

  Of course

  It can’t work

  Three years and two more marriage counselors after Honduras, I hadn’t had a drink in five years. I smashed a glass at my wife’s feet and broke an expensive tile. The next day I pushed a chair she was in.

  I had to leave.

  Whatever peace we had managed to work out couldn’t survive my not drinking.

  My wife and I had both come from damaged, damaging childhoods, and both of us desperately wanted to be normal and thought that being married to each other would be a ticket away from where we didn’t want to be. She liked the very un-needy Clint Eastwood–type man I had tried so hard to be. She had bragged to her women’s group about how little trouble I was. Now, suddenly, I was a jumpy mess who needed a drink and couldn’t have one. It was embarrassing for both of us that I had gone nuts and thrown those rocks out of the aquarium at her and been hauled off to the hospital in a straightjacket. You can’t go from being someone who drinks at least a little bit every day to someone who doesn’t drink like it’s wearing different clothes and cutting your hair shorter. She was a perfectly okay woman whom I didn’t feel loved by. I would have done anything except drink to have my own goddamned feelings matter less.

  What possibly could happen to a forty-five-year-old man with two kids that would make getting divorced come out okay?

  At my most pathetic, when I felt lost and very sorry for myself and was no longer in charge of making breakfast and packing lunches for my boys, I set up a bird feeder on the ledge of my apartment overlooking a parking lot and no birds came.

  End of the Lane, 1991

  (Painting by Mark Vonnegut)

  Use all the armor.

  (Photo by Barb Vonnegut)

  chapter 14

  The Myth of Mental Wellness

  Just ’cause there’s nothing wrong with you doesn’t make you right.

  Our medical school graduation speaker was a Jesuit psychiatrist who made me laugh and cry at the same time. At least one person in the world understood why I had become a doctor. So I made a mental note, with my two-year-old son, Zach, sitting on my lap, that should I ever need a psychiatrist again, he would be the guy.

  I started going to Ned as a patient in the fall of my internship year, right after my sister had a psychotic break that started with voices and not being able to eat or sleep after giving up drinking. At one point she lay down in the aisle of an airplane so that the Black Jesus and White Jesus could talk to each other. I had zero clue drinking was a problem for her. I just thought she was unhappy some of the time because she was married to a jerk.

  Harvard’s health services had taken me off lithium halfway through my second year, when I discovered during anatomy that my thyroid was enlarged. After an ultrasound and a bunch of blood tests, it was determined that I had benign nodular thyromegaly and that the lithium the “vitamin doctors” had put me on might have something to do with it. I had some unsatisfactory sessions with the medical school shrink, who was annoyingly smug and fatherly. He didn’t have a diagnosis for whatever it was that had caused the three psychotic episodes in British Columbia, but going off the lithium was fine with me. I felt pretty much okay and all set forever.

  When my sister got sick I hadn’t taken lithium for two years and my thyroid was still three times its normal size and lumpy. I was shaken and upset because no one else in my family seemed to be able to get it together to deal with anything and because there were too many dead-ringer parallels between my sister’s psychosis and mine and I still had no name for whatever it was I had. This was in 1979, eight years after my initial episodes. How could I be so sure I was finished with it if I didn’t know what it was?

  I was the model of efficiency helping my sister in New York, at least partly because I was looking forward to telling Ned how it went.

  I don’t tell Ned everything. The truth about the voices, my grandiosity, and flights of ideas would just upset him. He might feel the need to do something about them, and it would take more time than I have to reassure him that I’m really all right.

  NED: “So what about thinking that people don’t know who you really are or that the radio is talking about you or to you?”

  ME: “Not me, boss.”

  The truth about the voices is that once you’ve heard them, they are always there, just more or less offstage and more or less intelligible. Once you’ve been talked to by voices, it’s not possible to go back to a world where talking to voices is not possible. Having been crazy, I know that God can, if He wants, run me like a toy train.

  NED: “Do you ever ask God to help you with a diagnosis?”

  ME: “No.”

  I actually had tried that and found out that physical diagnosis wasn’t one of God’s strengths. To be precise, what He said was, “Why do you think I created Harvard? I wouldn’t have bothered to send you to medical school if I knew you were going to come back to me with questions about physical diagnosis. You already know the patient doesn’t have appendicitis. Don’t bother me with crap like this again.”

  “But… ”

  So if I’m really so all right, why do I go see a psychiatrist at all?

  Over the years I’ve come to care about Ned, and I think I go mostly to make sure he’s okay. He comforts me about my increasingly balky memory and moodiness by assuring me that his memory and tendency to fly off the handle are worse than mine. It works for me.

  I still consider myself an early-Christianity scholar on a spiritual quest that happened to lead to medical school. Ned and I don’t talk much about early Christianity, but we could. I have a problem with Saint Paul, who never actually met Jesus, and with whoever it was who wrote the book of Revelation (it was definitely not Saint John). I also take issue with the idea that Jesus, after the Crucifixion and Resurrection, started working out and riding horses and having second thoughts about the Sermon on the Mount and the beatitudes. Where did this new muscular Christ come from? What are the four horsemen of the apocalypse so pissed about? What situation could possibly be made better by unleashing war, pestilence, famine, and death?

  Passing for normal hasn’t been a problem for me for a while now. I know how to dress and act and how to not exactly tell the truth about what’s going on. I could pass off the things that happened to me when I was crazy as just a bunch of craziness, but the problem is, when I’m trying my best to tell the truth to myself, I’m not sure I didn’t bargain God down from nuclear cataclysm to a relatively mild earthquake and stop my father from killing himself. I’m glad I got to meet and talk to Dostoyevsky, van Gogh, Beethoven, Freud, and Abraham Lincoln and continue to count them as good friends.

  There was one thing I was very sure of in early sobriety, and that was that I shouldn’t talk to the woman who casually complimented my haircut one day. I knew that my friend Max knew her phone number—he owned the apartment she was living in—and I didn’t want not having her phone number to be the reason I wasn’t calli
ng her. You have to wake up very early if you want to try to outthink me.

  We had had a few tentative dates after we were recruited to help out an underpowered softball team. I think it was the IT-support department of Boston University. I was coaching first base, and she hit a solid line drive in the gap between right and center field, so when she got to first I told her to go to second. She stopped dead in her tracks, turned to me, and said, “Don’t tell me what to do.”

  We were married six years later.

  ——

  It hasn’t escaped Barb that I go to my psychiatrist mostly to see how he’s doing. She’s not sure I shouldn’t see someone else.

  “They’d have problems too,” I point out. “Then I’d have two psychiatrists to worry about.”

  The difference between me and crazy people who have not done well is not much. Melville Weston Fuller Wallace III was one of my mother’s favorite friends of mine. We met working together at a restaurant when we were both seventeen. He lived mostly at our house one summer, and one of my sisters had a crush on him. One Fourth of July when I was nineteen I was visiting with him at his parents’ New York apartment. I had had too much to drink, and he was shushing me and taking care of me. He was no more or less schizophrenic than I was, but that’s his current diagnosis. He was a pretty good painter and a pretty good musician. I had my first episode three years later. He had his a year after that, when he was twenty-three. He and I have both been married twice. He’s homeless now and writes me heartbreakingly difficult-to-decipher letters and sends me beautiful geometric watercolors.

  I went looking for him once in L.A., along the Santa Monica boardwalk. It had been so long since I had seen Fuller that I had no idea what he might look like. I talked to about twenty people who might have been Fuller, and many of them thought they probably knew who I was talking about, but no one was sure. I showed them his paintings and said that he played the flute.